Introduction

The AUA 2023 Annual Meeting included an extremely active and robust program in the fields of reconstructive urology, trauma, and urinary diversion. A total of 140 abstracts in these topics were presented, including 2 podium sessions, 4 moderated poster sessions, and 3 video sessions, in addition to the well-attended Society of Genitourinary Reconstructive Surgeons (GURS) meeting and numerous varied presentations on reconstructive urology topics at the final day’s plenary session. Furthermore the “hot off the press” Updated AUA Guideline on Urethral Stricture was presented. In this article, we note some trends in the field of reconstructive urology, outline significant updates to the AUA Guideline on Urethral Stricture, and highlight key abstracts.

Trends

At AUA2023, it was clear that reconstructive urology as a subspecialty is experiencing a period of significant innovation and expansion. There is increasing utilization of robotic and minimally invasive surgical techniques across multiple reconstructive urology indications (representing 26% of abstracts presented) and marked interest in gender affirmation care (14% of abstracts presented).

Updated AUA Guideline on Urethral Stricture

The 2023 updates to the AUA Guideline on Urethral Stricture reflected progress in this area and knowledge gained since 2016. The addition of statement 11b, stating surgeons may offer urethral dilatation or direct visual internal urethrotomy, combined with drug-coated balloons, for recurrent bulbar urethral strictures <3 cm in length, reflected data based on a randomized controlled trial. Endoscopic treatment with the paclitaxel drug-coated balloon was reported to improve freedom from repeat intervention at 1-year follow-up compared to dilatation/direct visual internal urethrotomy alone (83.2% vs 21.7%).¹ Perineal urethrostomy was emphasized as an option for men at high risk for failure of urethral reconstruction, such as men with complex anterior urethral strictures particularly after failed prior repairs. Buccal and lingual grafts were noted as equivalent alternatives. There was new mention of female urethral strictures in the guidelines, stating that surgeons may use oral mucosal grafts, vaginal flaps, or a combination of these techniques, and new inclusion of a robotic approach for reconstruction of recalcitrant bladder neck contracture or post-prostatectomy vesicourethral anastomotic stenosis (VUAS).²

Trauma

Several abstracts were presented on the role of nonoperative management of renal trauma, as well as factors associated with various interventions. Dr Patel queried the National Trauma Database of over 49,000 patients and presented factors associated with intervention, which showed that there are patient-, hospital-, and clinical-specific factors associated with nephrectomy, as well as age as an independent factor, and that more conservative use of nephrectomy is required especially among older patients.³

Dr Meyers delivered an excellent presentation during the GURS session regarding acute management of pelvic fracture urethral injury, presenting data from a prospective multicenter research protocol: Outcomes of [Endoscopic] Urethral Realignment (EUR) vs Suprapubic Cystostomy (SPT) After Pelvic Fracture Urethral Injury.⁴ Obstruction occurred in 97% after EUR, 94% after SPT, and urethroplasty was performed in 89% of patients after EUR vs 91% in the SPT group (unpublished data).

Reconstruction

There were many abstracts presented on robotic techniques for various upper and lower urinary tract reconstruction surgeries. Dr Cho presented a proposed classification system for ureteral strictures to create standard nomenclature to allow for better characterization and assessment of outcomes.⁵ cLSM (the Ureteral Stricture Clinical Classification System) incorporates Length of stricture (L1-3), Segment (S1-S6), and Modifiers (O, M), and the final ureteral classification system will include Etiology (cLSE) to further characterize ureteral injuries and compare reconstructive operative techniques.

Dr Wang presented a series of 105 patients who underwent posterior urethroplasty for VUAS, which involved some cases being performed as robotic abdominal, perineal, or combination robotic abdominal and perineal approaches, and involved various techniques including bladder flap, oral mucosa graft, excision, and primary anastomosis. Robotic outcomes were similar to those in the literature for open posterior urethroplasty; however, continence rates were more favorable (20% vs 66%-85% for VUAS, and 37% vs 50% for VUAS post-radiation).⁶

Dr Erickson presented in the GURS session and led an interesting panel discussion in the plenary regarding evaluation and management of adult-acquired buried penis syndrome. The importance of physical examination was emphasized, with an appreciation of the proposed classification system which classifies the condition by the status of the abdominal pannus, the escutcheon, the penile skin, and the scrotal skin, and their respective fascial attachments. Various surgical strategies to repair adult-acquired buried penis syndrome were discussed with surgeons cognizant of patient-centered goals, counseling, and shared decision-making.

Gender Affirmation

The trend this year was a focus on assessing outcomes and predictors of risk in gender-affirming surgery, complications and avenues for improvement, with some abstracts evaluating technique as well. A best poster prize was awarded to Dr Victor, who conducted a retrospective chart review which concluded that pre-vaginoplasty gender-affirming bilateral orchiectomy could offer several specific medical benefits, such as the benefits of significantly lower daily gender-affirming feminizing hormone therapy (typically estrogen and an antiandrogen) medications and dosages, and improved quality of life related to elimination of antiandrogen side effects, particularly in the context of long (1- to 4-year) surgery wait times at high-volume centers.⁷

Closing Remarks

The 2023 AUA Annual Meeting was indeed a robust and invigorating meeting for those practicing and interested in the field of reconstructive urology. The specialty is experiencing an exciting time of growth in experience, knowledge, quality, and breadth, as evidenced by the numerous varied abstract presentations, plenary presentations, and content-packed GURS session. Trends include an expansion of innovation and interest in robotic reconstructive surgery and gender affirmation care. No doubt, AUA2024 will also be a productive meeting to anticipate, and just as we have experienced in 2023, we expect further great work to be showcased there from the best minds and institutions in the U.S. and around the world.